Research Article: Effectiveness of an intervention to facilitate prompt referral to memory clinics in the United Kingdom: Cluster randomised controlled trial

Date Published: March 14, 2017

Publisher: Public Library of Science

Author(s): Gill Livingston, Gianluca Baio, Andrew Sommerlad, Simon de Lusignan, Spyridon Poulimenos, Steve Morris, Greta Rait, Juanita Hoe, Bruce L Miller

Abstract: BackgroundMost people with dementia do not receive timely diagnosis, preventing them from making informed plans about their future and accessing services. Many countries have a policy to increase timely diagnosis, but trials aimed at changing general practitioner (GP) practice have been unsuccessful. We aimed to assess whether a GP’s personal letter, with an evidence-based leaflet about overcoming barriers to accessing help for memory problems—aimed at empowering patients and families—increases timely dementia diagnosis and patient presentation to general practice.Methods and findingMulticentre, cluster-randomised controlled trial with raters masked to an online computer-generated randomisation system assessing 1 y outcome. We recruited 22 general practices (August 2013–September 2014) and 13 corresponding secondary care memory services in London, Hertfordshire, and Essex, United Kingdom. Eligible patients were aged ≥70 y, without a known diagnosis of dementia, living in their own homes. There were 6,387 such patients in 11 intervention practices and 8,171 in the control practices. The primary outcome was cognitive severity on Mini Mental State Examination (MMSE). Main secondary outcomes were proportion of patients consulting their GP with suspected memory disorders and proportion of those referred to memory clinics. There was no between-group difference in cognitive severity at diagnosis (99 intervention, mean MMSE = 22.04, 95% confidence intervals (CIs) = 20.95 to 23.13; 124 control, mean MMSE = 22.59, 95% CI = 21.58 to 23.6; p = 0.48). GP consultations with patients with suspected memory disorders increased in intervention versus control group (odds ratio = 1.41; 95% CI = 1.28, 1.54). There was no between-group difference in the proportions of patients referred to memory clinics (166, 2.5%; 220, 2.7%; p = .077 respectively). The study was limited as we do not know whether the additional patients presenting to GPs had objective as well as subjective memory problems and therefore should have been referred. In addition, we aimed to empower patients but did not do anything to change GP practice.ConclusionsOur intervention to access timely dementia diagnosis resulted in more patients presenting to GPs with memory problems, but no diagnoses increase. We are uncertain as to the reason for this and do not know whether empowering the public and targeting GPs would have resulted in a successful intervention. Future interventions should be targeted at both patients and GPs.Trial registrationCurrent Controlled Trials ISRCTN19216873

Partial Text: The number of people with dementia is increasing worldwide as the population ages [1]. Across developed countries, many people with dementia never receive a diagnosis, while others receive one late in the illness [2]. Our systematic review of interventions to increase the rates of dementia diagnosis reports no clearly successful intervention; although educating general practitioners (GPs) increased their ability to diagnose dementia, this approach did not result in increased diagnostic rates [3]. Currently, the dementias are incurable, but early diagnosis allows people to plan for the future [4], receive treatment to reduce cognitive and neuropsychiatric symptoms [5,6], and access social and voluntary care. Early diagnosis also helps family carers [7], reduces crises, and delays care home entry [8] for people with dementia with little negative effects [9].

We approached 43 practices, and 22 were randomised. The consolidated reporting of trials (CONSORT: Fig 1) diagram shows practices’ and patients’ progress through the trial. We recruited GP practices between 16th August 2013 and 14th December 2013 and the corresponding memory services between 11th December 2013 and 23rd September 2014. All memory services linked to the practices included in the study were recruited. We collected follow-up data from participating memory services between 16th April 2014 and 2nd October 2015. We stopped the trial once we had recruited the practices and follow-up was completed. Table 1 shows the baseline characteristics of those presenting to memory clinics with a suspected diagnosis of dementia. As expected, the majority of patients were female and the mean age was around 80-y-old.

There was no between-group difference in our primary outcome, cognitive severity at diagnosis. Our intervention was designed to empower patients and increase early diagnosis of dementia through increasing presentation to GPs with memory symptoms. The letters resulted in more people presenting to their GPs from the intervention practices with suspected memory problems. Although there was also a secular increase in GP referrals in both groups, GPs in the intervention group referred less of the people who presented to them with memory problems than in the nonintervention group. We do not know whether the extra patients presenting but not referred were worried well or had cognitive deficits, but overall in both groups there was no increase in the MMSE at diagnosis over time, so GPs are not referring earlier.



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